Bankruptcy Questionnaire Template (Page 6 of 26) in pdf

Bankruptcy Questionnaire Template Page 6

List all income received so far this year and in the last two years by you or your spouse:

Source

(Names and addresses of

Income Received

employers or specify social security,

By Whom

(Give gross income as

welfare, unemployment, child support,

reported on tax returns)

self-employment, investments, etc.)

(Self or spouse)

So far this year:

Last year:

Year before last:

G. Have you or your spouse been in business by yourself or with others during the last six years?

YES ____ NO ____. If yes, give the dates, name of the business, its address, and the names of others in business

with you or your spouse.

H. Are there any debts from your former business? YES ___ NO ___. If YES, list them in questions 32 and 33 and

give details here:

(1) If you employed anyone (such as regular employees, cleaning people, gardeners, babysitters), do you still

owe them wages? YES ___ NO ___. If YES, give name and address of employee, dates worked, amount

owed, and work done.

(2) Has anyone given you money to purchase property or services that you were unable to provide?

YES ___ NO ___. If YES, give details:

Have you ever been on welfare within the past two years? YES ___ NO ___. Has anyone in your immediate

family? YES ___ NO ___. If YES to either question, specify the persons, dates, amounts received, and places

(if state welfare, name the state; if local welfare, name the city or county).

K. Have you ever received or been told you have received more money from the government than you were

supposed to (such as social security, welfare, unemployment compensation, food stamps, etc.)?

YES _____ NO _____. If YES, give details:

Do you have any vacation time that is due you from your employer? YES _____ NO _____. If YES, how much is

due?

Bankruptcy Questionnaire Template Page 6